Retrospective analysis of four-year injury data from the Infantry Training Centre, Catterick

Abstract

Introduction
Musculoskeletal injury (MSKI) represents a considerable threat to the effectiveness and productivity of military organisations globally. The impact on the medical chain, occupational disposal with associated loss of working days and associated financial burden have far-reaching consequence. The moral and legal responsibility to reduce avoidable injuries through risk assessment and prevention strategies is fundamental to governance and a key component of best practice.

Methods
A retrospective observational analysis was performed of 4101 MSKIs presenting from a total inflow of 10 498 British Army Infantry recruits recorded over four consecutive training years between 2012 and 2016. Injury incidence, site, type and week of training were recorded and analysed.

Results
The total incidence of all MSKI was observed as 39.1%. Overuse injuries were the most common subclassification of injury type (24.5%), followed by trauma (8.8%) and then stress fractures (5.7%). Causes of medical discharge over a four-year cumulative incidence were from overuse injuries (59.3%), stress fractures (21.5%) and trauma (19.2%). 45.5% of all MSKIs presented within the first eight weeks of training.

Conclusions
MSKI data highlighted the requirement for a comprehensive service evaluation of the Combat Infantryman’s Course and subsequent justification for the introduction of an injury prevention intervention — Project OMEGA.

Full text

35
Heagerty R, etal. J R Army Med Corps 2018;164:35–40. doi:10.1136/jramc-2017-000777
Original paper
Retrospective analysis of four-year injury data from
the Infantry Training Centre,Catterick
Robert Heagerty,1 J Sharma,1,2 J Cayton,1,3 N Goodwin3
To cite: HeagertyR,
SharmaJ, CaytonJ, etal.
J R Army Med Corps
2018;164:35–40.
1PCRF ITS, Physio Department,
Catterick Garrison, UK
2Teesside University,
Middlesborough, UK
3RRU Catterick, UK
Correspondence to
Major Robert Heagerty, PCRF,
Infantry Training Centre, Vimy
Barracks, Catterick, Catterick
Garrison, North Yorkshire DL9
3PS, UK; robheagerty@ me. com
Received 7 March 2017
Revised 23 June 2017
Accepted 27 June 2017
Published Online First
22August2017
ABSTRACT
Introduction Musculoskeletal injury (MSKI) represents
a considerable threat to the effectiveness and produc-
tivity of military organisations globally. The impact on the
medical chain, occupational disposal with associated loss
of working days and associated financial burden have
far-reaching consequence. The moral and legal responsi-
bility to reduce avoidable injuries through risk assessment
and prevention strategies is fundamental to governance
and a key component of best practice.
Methods A retrospective observational analysis was
performed of 4101 MSKIs presenting from a total inflow
of 10 498 British Army Infantry recruits recorded over four
consecutive training years between 2012 and 2016. Injury
incidence, site, type and week of training were recorded
and analysed.
Results The total incidence of all MSKI was observed
as 39.1%. Overuse injuries were the most common
subclassification of injury type (24.5%), followed by
trauma (8.8%) and then stress fractures (5.7%). Causes
of medical discharge over a four-year cumulative inci-
dence were from overuse injuries (59.3%), stress frac-
tures (21.5%) and trauma (19.2%). 45.5% of all MSKIs
presented within the first eight weeks of training.
Conclusions MSKI data highlighted the requirement
for a comprehensive service evaluation of the Combat
Infantryman’s Course and subsequent justification for
the introduction of an injury prevention intervention —
Project OMEGA.
INTRODUCTION
Infantry training courses within the UK military
The Infantry Training Centre (ITC), Catterick is a
phase 1 and 2 military training establishment with
capacity to provide instruction to up to 4000 recruits
per year.1 The Combat Infantryman’s Course (CIC)
is considered the most physically arduous and
demanding of all initial military training courses
in the British Army1–3 and is delivered over a
minimum of 26 weeks to recruits allocated to eight
training companies under command of two Infantry
Training Battalions. 1 Infantry training Battalion
consists of five standard (line) infantry divisional
companies, and 2 Infantry Training Battalion
consists of guards, parachute regiment and Gurkha
soldiers. The training content is a blend of generic
military training and unit-specific soldiering skills.
In addition, the Guards Company has a focus on
drill, and the Parachute Company focuses on the
arduous parachute selection course.1 Gurkha
training, lasting 39 weeks, is the longest due to
its incorporation of additional packages such as
linguistics, cultural education, tactical close combat
and martial arts training. The intent for all training
teams is to transform young civilians into class 3
infanteers ready to join the British Army.
Musculoskeletal injuries in military
Ongoing service evaluation and quality improve-
ment is an imperative reflected in the ITC’s mission
statement.4 Musculoskeletal injury (MSKI) is
recognised both in the UK and globally as a signif-
icant challenge to military efficiency.1 5–16 MSKI
has a negative impact on morbidity, training time,
resources and manning.1 7–20 It is also a potential
threat to the effectiveness and productivity of the
ITC, with a subsequent impact on the supply of
trained personnel to the wider military.1 4 14 18 20 The
increased burden on the medical chain, loss of days
in training due to temporary downgrade, place-
ment on light duties and potential risk of subse-
quent medical discharge (MD) present an ongoing
challenge to organisational effectiveness.1 14 18 The
associated wastage contributes to compromised
operational capability and presents a significant
financial loss.1 5 7 11 14 16 18–21 As potentially career
and therefore life-changing events, in the physical
domain but seen increasingly from a psychological
perspective, MSKI can have significant impact on
the individuals affected.1 2 5 7 10 11 18 20–25
Key messages
►Incidence of musculoskeletal training injuries
within military populations is recognised
globally to have detrimental impact on wastage
and organisational effectiveness.
►There is a strong professional and moral
responsibility to understand and address the
causation of potentially reducible training
injuries.
►Injuries to the lower limb, specifically the
knee, were the most frequently reported, while
highimpact activity was identified as the most
common cause.
►Injury incidence was the highest in the first
two weeks of infantry training, with the majority
of all injuries reported in the first eight weeks.
►Of all subclassifications of injury, overuse
injuries were the most common cause of
medical discharge.
►Effective injury prevention strategies should
address the multifactorial nature of military
training injuries. Professional and moral
accountability resulted in the implementation of
Project OMEGA.
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36 Heagerty R, etal. J R Army Med Corps 2018;164:35–40. doi:10.1136/jramc-2017-000777
Original paper
Although the global appetite to identify effective injury
prevention strategies is strong, population-specific epide-
miological data are limited.11 Accumulating accurate and
meaningful injury data is a prerequisite to identifying injury
patterns and determining the direction of subsequent
interventions.5 7 10–12 18–20 22–27 The aim of this paper is to present
retrospective trend analysis of the incidence and subclassifications
of all MSKI episodes referred to a physiotherapy department over
a four-year period.
METHODS
The ITC Primary Care Rehabilitation Facility (PCRF) has main-
tained a register of injury data since 1 April 2012. Administrative
staff prospectively enter MSKI data with senior physiotherapy
staff. Causality categories are divided into injuries attributed
directly to infantry recruit training (phase 1 and 2), injuries
due to playing sport and injuries sustained in non-working time
(Table 1). Every MSKI is presented as a new separate case. Repeat
injuries within four weeks of initial presentation are recorded
within the original recorded episode of care. Overuse injury
(non-fracture) were distinguished from overuse stress fracture.
A single training year runs between 1 April and 31 March.
The spreadsheet is password-protected and managed in accor-
dance with Caldicott guidelines. The MSKI data between 1 April
2012 to 31 March 2016 were reviewed for targeted trend anal-
ysis. Non-training MSKI such as those acquired from domestic
causes, for example road traffic accidents or weekend sports, were
excluded. In addition, injuries reported by personnel on military
short courses were not included in this analysis. This paper did not
investigate intercompany injury patterns.
Data analysis
Data were analysed descriptively by site, type, rate and time of
presentation. All data were independently checked for accuracy
by the clinical administration assistant, as well as three senior
members of the physiotherapy management team, prior to anal-
ysis. All MSKI data were considered in relation to the total annual
recruit inflow to ITC. All recruits entering ITC are nominally
and numerically registered according to their allocated training
company. The baseline data of total number of recruit inflow
for each regiment were retrieved from the Training, Administra-
tion and Financial Management Information System, and were
cross-referenced and confirmed as accurate against recruit intake
figures recorded by the ITC G7 Training Cell and key statis-
tical database for the School of Infantry. The injury data were
extracted and presented for all individual recruits commencing
the respective training years.
RESULTS
During this four-year period of study, 4101 MSKIs were
referred to the PCRF from a total inflow of 10 498 recruit
trainees. Table 2 presents the classification of MSKI by type as
a percentage of both the annual recruit inflow as well as the
number of referrals to physiotherapy for each training year. The
incidence of all reported MSKIs sustained by recruits across all
training companies undertaking the CIC varied from 32.5% to
50.1%, representing a total of four-year cumulative incidence,
with a 95% CI of 39.1% (95% CI 38.1 to 40.0).
Type of injury
The most common subclassification of injury type was overuse,
24.5% (95% CI 23.7 to 25.4), followed by trauma, 8.8% (95%
CI 8.3 to 9.4), and stress fractures 5.7% (95% CI 5.3 to 6.2).
Overuse injuries were observed to be the most common injury
(62.8%, 95% CI 61.3 to 64.2) presented by recruits to the
physiotherapy department, with all overuse MSKIs (including
stress fracture) representing a four-year cumulative incidence
of 77.5% (Table 2). Overuse combined with stress fractures
represents a combined four-year cumulative incidence of 30.2%
of total recruit inflow, which equates to more than one in every
three recruits sustaining an overuse injury. The four-year cumu-
lative incidence for traumatic injuries was 8.8% (95% CI 8.3
to 9.4) of the total recruit inflow. The incidence of previously
sustained pre-existing injuries incurred prior to the individual
commencing recruit training at ITC equated to 11.9% (95% CI
11.3 to 12.5) of (total four-year cumulative incidence) annual
inflow or 30.4% (four-year cumulative incidence) of all injuries
referred to the PCRF.
Site of injury
Figure 1 shows the most common sites of diagnosed MSKI with
a 95% CI. The majority of injuries occurred to the lower limb,
most commonly at the knee (21.0%–25.8%), followed by the
ankle (16.6%–19.3%).
Reported causation
Figure 2 describes the injury causation with 95% CI. Notably,
for the four consecutive training years fast loaded marching
(‘tabbing’) has consistently been the most reported cause of
MSKI (36.9% to 40.1%), followed by trauma (19.8% to 23.0%),
field exercise (13.7% to 19.1%) and running (16.7% to 20.4%).
Week of injury
Figure 3 and table 3 illustrate the distribution of all MSKIs
presented during this four-year period. The week of peak injury
Table 1 Data fields included within the injury database
Patient Injury Training Rehabilitation summary
Service number Date of injury Week of Trg Days in physiotherapy
Unit (ie, Infantry Training Centre) Date presented to Primary Care
Rehabilitation Facility
Days out of training Weeks in physiotherapy
Regt(ie, line infantry, para, guards or Gurkha) Injury type(ie, trauma, overuse) Days in rehabilitation platoon Number physiotherapy appointments
Ethnicity Injury site(ie, spine/hip/knee/ankle/foot) Date of discharge Weeks in rehabilitation platoon
Gender Pre-existinginjury status Outcome(ie, return to training/medical
discharge)
Stress fracture site
Stress fracture diagnosis
Patient perceived cause injury
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Heagerty R, etal. J R Army Med Corps 2018;164:35–40. doi:10.1136/jramc-2017-000777
Original paper
incidence was found to vary annually. However, the highest
recorded incidence of injury (across all four years) were observed
in weeks 1 (7.0%), 2 (8.5%), 3 (6.9%), 4 (6.8%), 8 (6.4%) and
14 (6.4%), with the majority (45.5%: 95% CI 44.0 to 47.1) of
all MSKIs presented in the first eight weeks of infantry training.
MSKI resulting in MD
Table 4 presents the MD according to subclassification of
MSKI. The most common causes of MD were overuse injuries
(non-stress fracture), 59.3% (95% CI 55.9 to 62.7), followed
by stress fracture, 21.5% (95% CI 18.8 to 24.5), and trauma,
19.2% (95% CI 16.7 to 22.1).
DISCUSSION
This review analysed 4101 MSKIs referred to the physiotherapy
department from a total inflow of 10 498 recruit trainees at the
ITC between 1 April 2012 and 31 March 2016. The incidence
of all reported injuries sustained by recruits across all training
companies undertaking the CIC ranged from 32.5% to 50.1%
of the total recruit inflow. This equates to a four-year annual
cumulative incidence of 39.1%, which falls within the values
(20%–59%) reported previously across other military popula-
tions.1 5 9 16 24
There is some variation in the pattern of annual injury incidence
over the last four training years. It is recognised that MSKIs are
multifactorial in origin, and as such it may be tenuous to attri-
bute a single intervention to either increments or reductions
in incidence. However, it may be suggested that targeted injury
prevention strategies could have contributed to the reduced injury
incidence in training years 2013/2014 and 2015/2016. These strat-
egies included the reduction in unnecessary ‘junk’ mileage previ-
ously incurred by the recruits transiting across the camp between
training serials, as well as the introduction of nutritional training
supplements. Similarly, the introduction of a variety of new mili-
tary boots in April 2013 may have contributed to a reduction in
ankle and foot injuries, as well as contributed to the lower attrition
rates during this period. Equally, it is interesting that prior to the
introduction of new military footwear, injuries to the foot were
the third most common (Figure 1), but then replaced by calf/shin
injuries after 2013.
Overuse (non-stress fracture) lower limb injuries have
consistently been the most common subclassification of MSKI
referred to physiotherapy in the recruit population at ITC
with a four-year cumulative incidence of 62.8% of all refer-
rals. Stress fractures are considered multifactorial in causation;
however, ultimately they represent a pathological response to
the body’s inability to efficiently dissipate applied load. The
nature of these injuries is such that the recruit is removed
from training for an extended period (up to four months) of
rehabilitation. As a consequence of overloading, they there-
fore represent a significant subset of the overuse injury cohort.
Consequently, total overuse MSKI (including stress fractures)
represent a four-year cumulative incidence of 77.5% of all
referrals to physiotherapy.
The prevalence of knee injuries (21.0%–25.8%; see figure 1)
observed in this study reflects findings previously described across
the literature, that between 20% and 40% of military training
injuries involve the knee.5 7 As a multiaxial joint it is capable
of multiplanar movement and as such is inherently susceptible
to both traumatic and overuse MSKI. In addition, both prox-
imal and distal movement dysfunctions can contribute to kinetic
changes, which may result in the development of MSKI at the
knee.27 Consequently, kinetic chain movement stability (static
Table 2 Musculoskeletal injury type as a percentage of total recruit inflow and referral to physiotherapy
Type 2012/2013 2013/2014 2014/2015 2015/2016
Four-year cumulative
incidence 95% CI
Inflow
n=3521
Physiotherapy
n=1403(39.8%)
Inflow
n=1922
Physiotherapy
n=964(50.1%)
Inflow
n=2543
Physiotherapy
n=917(36.1%)
Inflow
n=2512
Physiotherapy
n=817(32.1%)
Total Inflow: 10 498
Total referrals to
physiotherapy:4101
Incidence rate: 39.1% 38.13% to 40.0%
Overuse 921
(26.2%)
921
(65.6%)
551
(28.7%)
551
(57.2%)
582
(22.9%)
582
(63.5%)
520
(20.7%)
520
(63.6%)
Inflow: 24.5% 23.7% to 25.4%
Physiotherapy: 62.8% 61.3% to 64.2%
Trauma 307
(8.7%)
307
(21.9%)
242
(12.6%)
242
(25.1%)
198
(7.8%)
198
(21.6%)
178
(7.1%)
178
(21.8%)
Inflow: 8.8 .% 8.3% to 9.37%
Physiotherapy: 22.6% 21.3% to 23.9%
Stress fracture 175
(5.0%)
175
(12.5%)
171
(8.9%)
171
(17.7%)
137
(5.4%)
137
(14.9%)
119
(4.7%)
119
(14.6%)
Inflow: 5.7% 5.3% to 6.2%
Physiotherapy: 14.7% 13.6% to 15.8%
Pre-enlistment 411
(11.7%)
411
(29.3%)
260
(13.5%)
260
(27.0%)
308
(12.1%)
308
(33.6%)
267
(10.6%)
267
(32.7%)
Inflow: 11.9% 11.3% to 12.5%
Physiotherapy: 30.4% 28.9% to 31.8%
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38 Heagerty R, etal. J R Army Med Corps 2018;164:35–40. doi:10.1136/jramc-2017-000777
Original paper
Figure 1 The most common area of injury (as a % of total injuries referred to physiotherapy).CIC,Combat Infantryman’s Course.
Figure 2 The most common reported cause of injury (as a % of injuries referred to physiotherapy).CIC,Combat Infantryman’s Course.
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Heagerty R, etal. J R Army Med Corps 2018;164:35–40. doi:10.1136/jramc-2017-000777
Original paper
and dynamic) should be carefully considered when constructing
injury prevention strategies.
There is a strong moral responsibility to investigate mech-
anisms of injury mitigation while professional accountability
to meet both internal and external drivers of governance to
prevent harm, reduce injury incidence and enhance service
delivery are constantly sought.5 14 Strategies specifically
designed to address the cause and mechanisms of injury have
shown the most benefit.10 Traditionally, a reduction in the abso-
lute volume of exercising mileage has been the most effective
intervention. A study of US Marine recruits showed that a 40%
(22 mile) reduction in running distance was associated with
a 54% reduction in stress fracture incidence during a Corps
Boot Camp with no significant change in run times.5 Similar
outcomes were obtained with Australian Army recruits, where
running was replaced with a graduated programme of loaded
foot marches resulting in a reduction of all lower limb injuries
by 43% and more specifically a reduction in knee injuries by
53%.4 Another study found that recruits undertaking initial
military training who ran an average of 11 miles per week
reported 27% more lower limb injuries than those running an
average of five miles per week.26
Lower limb stress fracture rates are reported to range globally
from 0.8% to 6.9% across initial entry military training popu-
lations.6 8 10 It is encouraging that the ITC has demonstrated a
reduction in annual incidence from a peak of 8.9% in 2013/2014
down to 4.7% in 2015/2016 (Table 1); however, mechanisms
to reduce all subclassifications of overuse MSKI must be inves-
tigated. The incidence of traumatic injuries has progressively
reduced from a four-year peak of 12.6% in 2013/2014 to a low
of 7.1% in 2015/2016. This may be a reflection of improving
health and safety management through increasingly robust
risk assessment as well as education of both training teams and
recruits. Excluding pre-enlistment injuries, traumatic MSKI, the
second most common subclassification of injury type, repre-
sented a four-year cumulative incidence of 8.8% (95% CI 8.3
to 9.4) of the total recruit inflow. Pre-enlistment MSKIs are
excluded from pure comparison with other subclassifications
as they represent a combination of both overuse and traumatic
injuries. Sustained high impact activities have consistently been
the most common cause of all MSKI at ITC. This is in keeping
with a plethora of international studies that acknowledge these
activities as potentially modifiable extrinsic factors for overuse
MSKI in both military and civilian populations.1 5 7 8 11 14 18–22
Forty-six per cent of all MSKIs were attributed to activity
within the first eight weeks of training, with noticeable peaks
between weeks 3 and 4 and again between weeks 8 and 10
(Table 3 and Figure 3). Despite the lack of knowledge regarding
recruits’ pre-enlistment fitness or the quality, quantity and
nature of their previous physical activity levels, it is reasonable
to suggest that, from a purely physiological perspective, those
individuals reporting overuse MSKI found difficulty coping with
the content, type, intensity and volume of the training. This is
particularly likely considering the incidence of overuse injury
in the first 12 weeks. Ultimately, this indicates a mismatch in
physical capacity/capability versus applied tissue loading, and
suggests a requirement to address this balance throughout the
course but particularly during the first half of training. Stress
Figure 3 Incidence of musculoskeletal injury attributed to specific week of training (as a % of injuries referred to physiotherapy).CIC,Combat
Infantryman’s Course.
Table 3 Cumulative percentage of total musculoskeletal injuries reported by week of training
Week of
training 2012/2013 2013/2014 2014/2015 2015/2016
Four-year cumulative
incidence 95% CI
4 25.4%(n=357) 22.6%(n=218) 27.4%(n=251) 21.3%(n=174) 24.4% (n=1000) 23.1% to 25.7%
8 47.5%(n=666) 42.8%(n=413) 47.2%(n=433) 43.5%(n=355) 45.5%(n=1867) 44.0% to 47.1%
16 77.8%(n=1091) 77.6%(n=748) 77.9%(n=715) 74.8%(n=611) 77.2%(n=3165) 75.9% to 78.4%
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40 Heagerty R, etal. J R Army Med Corps 2018;164:35–40. doi:10.1136/jramc-2017-000777
Original paper
fractures and all other (non-stress fracture) overuse injuries are
the subclassification of MSKI that are most likely to result in
subsequent MD (Table 4). This further reiterates the impact
that overuse MSKI has had on infantry recruits, resources of the
medical services, delivery of training, wastage of injured recruits
and ultimately organisational effectiveness. Successful strategies
designed to address the prevention of these MSKIs would there-
fore have far-reaching effect.
Careful consideration and modification of risk factors can
reduce the incidence of all injuries. Specific consideration of
the environment (terrain and climate) along with progressive
increments in distance, intensity and frequency accompanied by
adequate periods for rest and recovery have been advised.1 19–22
This is particularly relevant to those recruits who sustain overuse
injuries and serves as a recommended area for consideration in
future reviews of the content of infantry training at ITC. The
finding that 30% of injuries presenting to the PCRF were pre-en-
listment suggests the need for further analysis to investigate the
relationship between previous injury, performance and training
outcomes. The results of a follow-up investigation may have
implications for pre-enlistment medical screening criteria.
The prevalence of training injuries observed at ITC is not
unique to the British Army. The observations made from this
four-year analysis are consistent with those reported across
other NATO military populations.5–7 11 21–23 The responsibility
to investigate and address the cause is firmly recognised. Indeed,
a sense of urgency is reported, with strong recommendations
that proportional attention should be therefore dedicated to
the prevention of these potentially reducible injuries.5 7 10 11 18–20
These data have served as a basis for the introduction of an inte-
grated service evaluation and provided justification for the intro-
duction of an injury prevention strategy — Project OMEGA.15
If successful, this initiative could have a favourable impact on
injury incidence rates, time and finance lost to injury, as well
as identify areas for potential improvement to the content and
delivery of physical development training within the ITC.
CONCLUSIONS
It is imperative that accurate surveillance data are used to guide
the application of evidence-based interventions in order to
reduce the incidence of potentially avoidable MSKI. This four-
year retrospective analysis of recruit infantry training at ITC has
provided essential baseline data that could be used as rationale
for future injury prevention strategies.
Acknowledgements The authors acknowledge the considerable support of Col
Dalal L/RAMC, Col Byers L/RAMC, Lt Col Tingey Co Sp Bn ITC, Lt Col Booker RAMC,
Mrs S Mclaren, as well as the staff of the Medical Centre and PCRF at ITC Catterick.
Contributors All authors contributed to the collation, writing and editing of this
paper.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2018. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
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Table 4 Musculoskeletal injury resulting in medical discharge as a percentage of injury type
Type 2012/2013 2013/2014 2014/2015 2015/2016
Four-year cumulative
incidence(%) 95% CI
Stress fracture 18.0% (n=48) 25.9%(n=45) 23.1%(n=42) 20.8%(n=37) 21.5 18.8% to 24.5%
Overuse(non-fracture) 60.7%(n=162) 55.2%(n=96) 55.7%(n=105) 62.9%(n=112) 59.3 55.9% to 62.7%
Trauma 21.4%(n=57) 19.0%(n=33) 19.2%(n=35) 16.3%(n=29) 19.2 16.7% to 22.1%
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